Dengue: an added worry amidst the covid

pandemic
Sharp spike in dengue cases strains
Bangladesh’s healthcare system already
battered by a worsening COVID crisis.
Co-infection of Covid-19 and
dengue can be very difficult
to deal with, especially at a
time when healthcare
resources are exhausted
tackling the Covid pandemic.
Physicians need to be very careful with
fever patients………….
 RT-PCR/Rapid
antigen+Dengue
NS1 Ag

Both positive COVID positive Only dengue Both negative

positive

Dengue covid co- Strong suspicion Strong suspicion Clinical

infection Treat accordingly Treat accordingly of COVID of dengue correlation for
infection other infection

HRCT chest Repeat CBC and

serology
 Dengue and
covid 19
coinfection

symptomatic asymptomatic

Predominantly Co
dengue Predominantly dominant(severe
covid dengue with
severe covid)
 Concise Covid-19
management guideline in
Bangladesh
Mild Cases
Home Isolation

Clinical symptoms are mild ,no hypoxia or shortness of breath , no

. radiological evidence of pneumonia
 Recommendations
• Physical distancing from family member ,medical mask for both patient & Care giver.
• Symptomatic management: Paracetamol, hydration, Anti-histamine, Anti- tussive
• Follow up with a doctor through telemedicine
• Monitor temperature , Saturation
• only supportive care & rest for asymptomatic patient
• Thromboprophylaxis is not routinely indicated for mild cases except for Mild COVID
19 cases with multiple uncontrolled comorbidities and prothrombotic conditions:
Enoxaparin 40 mg, SC, once daily (OD)
 No role of Steroid: There is no role of systemic steroid in mild cases. Rather it may be
harmful if given during the viremic phase of the disease especially in the first 7 days
-Mild cases with controlled co-morbidities doesn’t need admission

 Danger sign (Go to hospital)

Breathing difficulties, chest pain, light headedness, disorientation, extreme weakness ,drop
in oxygen saturation ≤ 93%
 High Risk Patients (Hospitalization)
-Mild case with multiple uncontrolled comorbidities such as HTN, DM, IHD, CKD, CLD,
COPD/Asthma/ILD and prothrombotic state such as high risk-pregnancy and active
malignancy etc. should receive thromboprophylaxis and should be admitted.
Moderate cases
Hospitalization

Radiological Evidence of pneumonia, Respiratory distress or SpO2 90-93%

in Room Air

 Oxygen Support if needed

Target Oxygen: SpO2 > 92%
SpO2 : 88-92% in COPD Patient
 Awake Proning encouraged
 Remdisivir:
-Hypoxic patient , who required oxygen .
-Patient with high risk of disease progression
- Within 10 days of symptom onset.
 Systemic steroid :
Dexamethasone ,6 mg daily in hypoxic patient ,who required
oxygen.
 Anticoagulation:
- LMWH (Enoxaparin) at standard dose of 40 mg SC OD
For obese patients (BMI >40 kg/m2) LMWH, 40 mg SC BD

-If CrCl < 30 reduce the dose to 20 mg SC OD (both for obese and non-obese patient)

-If LMWH cannot be given or contraindicated, use unfractionated heparin (UFH). Dose of
unfractionated heparin: 5000unit SC BD
Severe cases
Hospitalization
Respiratory rate > 30 breaths/min; severe respiratory distress; or SpO2 < 90% on
room air
 Change of oxygen delivery device
.
Oxygen cannula ( up to 5 litre)
Oxygen mask ( 6-10 litre)
Non-Rebreather bag ( 10-15 litre)
 Remdisivir:
-Within 10 days of symptom onset.
 Systemic steroid :
- Inj. Dexamethasone 6 mg once daily for 7 to 10 days.
• Critical cases:
-HFNC, NIV CPAP, BiPAP
- Recognition of progressive acute hypoxemic respiratory failure, adequate preparation to ventilatory
support.
-Use conventional ARDS net protocol for ventilatory management.
- In adult patients with severe ARDS awake prone ventilation for 12–16 hours per day is recommended.
 Anticoagulation:
- Initiate Thromboprophylaxis (LMWH) in standard doses of 1mg/kg/day and assess the bleeding risk
-If CrCl <30 . LMWH 0.5 mg/kg SC OD.
- If LMWH cannot be given or contraindicated, use unfractionated heparin (UFH).
Dose of UFH: UFH 7500 Unit, SC, TID
 Supportive:
-Use a conservative fluid management strategy for ARDS patients
-Recognize septic shock in adults when infection is suspected /confirmed &vasopressors are needed to MAP
≥ 65 mmHg, lactate is ≥ 2 mmol/L, in the absence of hypervolemia.
Low-value medical care in the pandemic—is this what
the doctor ordered?
Lancet Glob Health 2021Published OnlineJune 2, 2021https://doi.org/10.1016/S2214-109X(21)00252-7

Azithromycin, doxycycline, ivermectin, A battery of diagnostic tests is also being

hydroxychloroquine, vitamin C, vitamin D, conducted for patients with COVID-19—
zinc, acetylcysteine, and inhaled blood counts, blood sugar, kidney and
budesonide or dexamethasone, liver function tests, D-dimer, interleukin-6,
Favipiravir procalcitonin, C-reactive protein, ferritin,
and lactate dehydrogenase.
Anticoagulants such as rivaroxaban These tests are repeated and treatment is
without increased thrombotic risk, against escalated on the basis of small changes in
the recommendations of most the results of these tests.
international expert panels.
Guidelines do not recommend these tests
Broad-spectrum antibiotics are added for patients with mild-to-moderate COVID-
under the pretext of treating secondary 19 disease because they do not inform
infections management decisions.
 According to the Directorate
General of Health Service
(DGHS), a total of 2,292
patients have been
diagnosed with dengue this
year

Just this month, 1,920 people were diagnosed with the

mosquito-borne disease till Friday, marking a more than
600 percent jump in cases from June when 272 cases
were reported
 Hospitals of Bangladesh are facing Co-Infection of
Covid 19 & Dengue Infection .
 The DNCC hospital saw patients with co-infection on
each of the past four days but the hospital authorities
would not reveal the number.
 The Mugda Medical College Hospital authorities
reported co-infection cases confirmed over the past
four days.
 The authorities of Dhaka Medical College Hospital,
BSMMU and 250-bed TB Hospital confirmed co-
infection cases as well.
 MILD covid with severe dengue

• Manage the patient as severe dengue

• Covid treatments are same as mild covid

management
Criteria of severe Dengue
 DHF without Shock
(Group-B)

The fluid requirement (oral + IV) in 48hrs

is calculated as Maintenance Fluid+ 5%
Deficit 4ml/kg/hr for first 10 kg weight
+
2ml/kg/hr for next 10kg weight +
1ml/kg/hr for subsequent kg body weight
+5% deficit
Treatment of Shock

 Compensated Shock
 Decompensated Shock
Compensated Shock

DSS is hypovolemic shock caused by plasma leakage and

characterized by increased systemic vascular resistance,
manifested by narrowed pulse pressure (systolic pressure is
maintained with increased diastolic pressure, e.g. 100/90 mmHg).

When hypotension is present, one should suspect that severe

bleeding, and often concealed gastrointestinal bleeding, may have
occurred in addition to the plasma leakage.

Most cases of DSS will respond to 10 ml/kg in children or 300–

500 ml in adults over one hour or by bolus .
Compensated Shock
Fluid management

 However, before reducing the rate of IV

replacement, the clinical condition, vital signs, urine
output and haematocrit levels should be checked
to ensure clinical improvement.
 It is essential that the rate of IV fluid be reduced
as peripheral perfusion improves; but it must be
continued for a minimum duration of 24 hours and
discontinued by 36 to 48 hours.
 Caution: Excessive fluids will cause massive
effusions due to the increased capillary
permeability.
DHF with
Compensated
Shock
 Decompensated shock (DSS, Profound
hypotension)

 Preferably this group of patient need to manage in ICU

setting.
 Oxygen should be started immediately.
 The bolus 10-20 ml/kg crystalloids should be given within 15-
30 min.

If the vital signs and Hct improved, If there is no clinical improvement after
the fluid can be reduced from 10 bolus crystalloids, check HcT. If the HcT is
ml/kg/hr to 6ml/kg/hr for 2 hours, raising (more than 45%, then the fluid
should be changed to colloid at (10-
then from 6 to 3 ml/kg/hr for 2-4
20ml/kg/hr) and if there is improvement,
hrs and then 3 to 1.5 ml/kg/hr for then changes the fluid to crystalloids and
another 2-4 hrs. Fluid should be successfully reduce as stated before. The
discontinued after 24-48 hrs. highest dose of colloid will be 30
ml/kg/24 hour.
Decompensated shock (DSS,
Profound hypotension)
 If the initial bolus crystalloids fluid does not have
improvement in vitals sign and HcT is reduced, then suspect
concealed bleeding and blood transfusion should be started
immediately at 10ml/kg whole blood or packed RBC at
5ml/kg.

 In case of refractory hypotension, look for ABCS

and IV inotropes with crystalloids as per
requirement is to be continued.

 In case of acidosis, hyperosmolar or ringers’

lactate should not be used.

 HcT measurement every hour is more important

than platelet count during management.
DHF with
Decompensated
Shock
Fluid Management in Children
Group B
Fluid Management in Children
Group C
When to stop intravenous fluid
therapy
 Cessation of plasma leakage;
 Stable BP, pulse and peripheral perfusion;
 Hematocrit decreases in the presence of a good pulse
volume;
 Apyrexia (without the use of antipyretics) for more than 24–
48 hours;
 Resolving bowel/abdominal symptoms;
 Improving urine output.
 Continuing intravenous fluid therapy beyond the 48 hours
of the critical phase will put the patient at risk of pulmonary
oedema and other complications such as thrombophlebitis.
Treatment of hemorrhagic
complications
Patients at risk of severe bleeding are those who:
 Have profound/prolonged/refractory shock;

 Have hypotensive shock and multi-organ failure

 Have pre-existing peptic ulcer disease;

 Have any form of trauma, including intramuscular

injection.
 Are given non-steroidal anti-inflammatory agents;

 Are on anticoagulant therapy;

 Severe Bleeding
Severe bleeding should be recognized in the following situations:
 Persistent and/or severe overt bleeding in the presence of unstable
haemodynamic status, regardless of the haematocrit level;
 Decrease in haematocrit after bolus of fluid resuscitation unstable

haemodynamic status;
 Refractory shock that fails to respond to consecutive fluid
resuscitation of 40– 60 ml/kg;
 Hypotensive shock with inappropriately low/normal haematocrit;

 Persistent or worsening metabolic acidosis;

 Well-maintained systolic BP, especially in those with severe

tenderness and distension.
The action plan for the treatment
of hemorrhagic complications
• If possible, attempts should be made to stop bleeding if
the source of bleeding is identified e.g. severe epistaxis
may be controlled by nasal adrenaline packing.
• Give aliquots of 5−10 ml/kg of fresh -packed red cells
or 10−20 ml/kg. Of fresh whole blood (FWB) at an
appropriate rate and observe the clinical response.
• It is important that fresh whole blood or fresh red cells
are given.
• Oxygen inhalation-2-4 L/min
• Consider repeating the blood transfusion if there is
further overt blood loss or no appropriate rise in
haematocrit after blood transfusion in an unstable patient.
Severe COVID with Dengue(without
warning sign)

Patient should be treated

as severe COVID
New recommendation in NIH
guideline
 Previous
• Baricitinib should not be used along with
Dexamethasone and without Ramdisivir
 New
• Baricitinib can be used along with Dexamethasone
if there is increasing O2 demand with or without
Ramdisivir
Some controversies are there
 Treatments having conflict of interest

 FLUID THERAPY

 ANTICOAGULATION

 CORTICOSTEROID
Fluid therapy
 Fluid resuscitation should be based on pulse pressure variation,
body temperature, capillary refilling and/or lactate level rather
than central venous pressure, mean arterial pressure

 Oral replacement is preferable over intravenous replacement

 For the acute resuscitation using buffered/balanced crystalloids(Ringers
lactate) over unbalanced crystalloids (0.9% Nacl)
 For the acute resuscitation the initial use of albumin in not recommended.
 Using hydroxyethyl starches for intravascular volume replacement is not
recommended
Anticoagulation
 Decisions about anticoagulation in patients with
thrombocytopenia must balance the risks of thrombosis and
thrombosis progression with the risks of bleeding due to
thrombocytopenia as well as other bleeding risk factors.

Bleeding risk is higher in individuals with platelet counts

<50,000/microL, and severe spontaneous bleeding is most
likely with platelet counts <10,000/microL

Hospitalized patient can receive anti coagulant if indicated

except platelet count is less than 30,000 or there is active
bleeding
Anticoagulation
 If there is evidence of arterial or venous thrombosis with
platelet count <30,000 then anticoagulant can be given
following platelet concentrate transfusion
 Short acting anticoagulant (unfractionated heparin) is
preferred over long acting anticoagulant (LMWH)

 Concomitant use of other medication which increase risk of

bleeding should be temporarily withheld when platelet count
is less than 50,000 (antiplatelet, Nintedanib etc.)
Anticoagulation

 Non pharmacologic intervention can be employed

to prevent VTE intermittent pneumatic compression
and graduated compression stockings
 Frequent close monitoring of platelet count is very
important specially during critical phase of dengue
Steroid
 Steroid is not recommended for treatment in Dengue
 But in life saving in severe COVID-19 infection steroid
can be used at any stage of dengue if it is indicated
for severe COVID

High receptor affinity steroid ( Methyl prednisolone) have

shown some benefit in DHF and DSS . So it can be an
alternative of Dexamethasone in severe COVID and
Dengue co infection
Scenario 1
 Scenario 1
 A 28-year-old man presents to you with abdominal pain and persisted
vomiting for 1 day.
 5 days before these presentations, he had fever, headache including
retroorbital pain, myalgias, arthralgia especially knee and shoulder,
and took paracetamol at standard dosages on his own.
 On the fourth day of symptoms, after a decrease in fever and
headache, he had abdominal pain and repeated vomiting. On query,
he denied any bleeding from any orifice.

On evaluation, he is well-nourished, anicteric. There is 110/70 mm

Hg of blood pressure and 90 beats per minutes of heart rate,
normal temperature and 18 breath per minute of respiratory rate.
 You are attending physician. Your clinical diagnosis is dengue
virus infection. Understand the covert haemorrhagic
manifestation clinically what will you do in this case?

Tourniquet test
 You have done the tourniquet test and found it positive. Your clinical
diagnosis is dengue haemorrhagic fever. What is your conclusion
regarding the clinical phase he is in now?

Critical phase
In this stage, to see the evidence of plasma leakage, clinically what will
you do?

o Capillary refilling time

o Pulse pressure
o Examination for pleural
effusion
o Examination for ascites
Tourniquet Test

 A tourniquet test is often positive.

 This test is performed by inflating a blood pressure cuff on
the upper arm to midway between diastolic and systolic
blood pressures for 5 minutes.
 The results are considered to be positive if more than 20
petechiae per square inch are observed on the skin in the
area that was under pressure.

 Skin Rash
 Up to half of the patients with dengue fever develop a
characteristics rash
Scenario 2
Scenario 2

 A 30-year-old young man, from Narayangonj, presents with

generalized body ache and high fever (highest recorded
temperature 39·4 °C), for 4 days and rash for 1 day.

 On physical examination, he is conscious, dehydrated with a

heart rate 100/min, blood pressure 100/60 mmHg. There is
a rash in the whole body, predominantly on his upper limbs.
Tourniquet test is positive. Capillary refill time less than 2
seconds. There are features of small right sided pleural
effusion and no evidence of ascites clinically.
 As per history and examination, this patient is in
a critical phase. To distinguish compensated
shock, what would you do preferably?

Examination for
postural hypotension
Scenario 3
Scenario 3
 A 21-year-old male, come from Kalabagan, Dhaka,
presents with an acute onset of high-grade continued
fever and body ache for 3 days. He also complains
of nausea and vomiting occasionally. There is no rash
and no bleeding from any orifice.
 On examination, he is conscious, pulse 100/min,
blood pressure 110/70 mm Hg, temperature 102 F,
respiratory rate 18 breaths/ min. Tourniquet test is
positive. Systemic examination revealed no evidence
of pleural effusion or ascites.
 You are an attending physician. Your clinical diagnosis is
dengue fever. In history, to find out the other warning
signs of dengue, which additional points should be
taken?
Vomiting
Mucosal bleeding
Abdominal pain or tenderness
Lethargy or restlessness

 You are an attending physician. Your clinical diagnosis is

dengue fever without warning signs. How to confirm your
diagnosis on day 03?

Dengue NS1 antigen

Key Notes

 If fever for 1-5 days, tests – CBC, NS1 antigen should be done during the
first consultation to get the baseline characteristics like hematocrit and
complete blood count if the patient presented within 3 days of fever.
 Follow up testing may be done on 1st afebrile day but should be done
daily once DHF is suspected.
 A regular hematocrit is more important for management than the
thrombocytopenia.
 A hematocrit level increase greater than 20% is a sign of
hemoconcentration and precedes shock. The hematocrit level should be
monitored at least every 24 hours to facilitate early recognition of dengue
hemorrhagic fever and every 3-4 hours in severe cases of dengue
hemorrhagic fever or dengue shock syndrome.
 Once the platelet count begins to rise and reaches ≥ 50,000/mm3, daily
lab evaluations may be discontinued.
 After 7 days of fever, IgM, IgG antibody for dengue can be done for
diagnosis
Scenario 4
Scenario 4
 A 55-year-old male from Dhanmondi, Dhaka presents
with a 4-day history of fever, arthralgia, myalgia and 3-
days history of headache with retroorbital pain. On
query, he has had postural dizziness, nausea, vomiting
and right upper abdominal pain.
 On examination, he is oriented but dehydrated with
capillary refilling time less than 2 seconds with warm
peripheries. Pulse is 96 b/m with a supine BP of 110/70
mm Hg and standing BP of 105/85 mm Hg. Reduced
breath sounds are noted in the right lung base. There is
marked tenderness over the right hypochondrium with
hepatomegaly of 4 cm below the costal margin. He does
not have clinically detectable ascites in the abdomen.
 You are the attending physician, and after taking the
history, dengue fever is suspected. What would be the
most appropriate measures you take in this case?
 Needs admission for rapid fluid
replacement as he approaches the
critical phase to prevent progression to
the shock state

In the next step of management, you feel hesitation regarding

the choice of isotonic solution. You are the only physician to
take the decision. Which of the following isotonic solution is
preferable to be administered in this case?
 Normal saline
Scenario 5
Scenario 5

 A 43-year-old woman presented with a history of intermittent fever for

one week with vomiting episodes 2-3 times a day. There is no diarrhea.
Oral intake is reduced. There is no giddiness and urine output is good
(the patient passed urine 6 times in the 24 hours before admission).
 Physical examinations are unremarkable with a blood pressure of
110/70 mmHg on lying and 100/85 mm Hg on standing after 3
minutes, a regular pulse rate of 90 beats per minute, a temperature of
37°C and respiratory rate of 18 breaths per minutes with
unremarkable abdominal and respiratory clinical findings. Tourniquet
test is positive. Peripheral circulatory perfusion is good and hydration
status is good. Her last paracetamol intake is 72 hours ago. A full
blood count is collected. It shows a hemoglobin 15.1 g/L, hematocrit
50%, platelet count 15 x 109cells/L and white blood cell count of
4.3 x 109 cells/L. Dengue Ig M antibody is positive. A clinical
diagnosis of severe dengue fever in the defervescence stage is made.
As you are an attending physician in an out-patient
clinic, what would be the best decision regarding this
case from your medical point of view?

 Immediately admission to hospital and

start normal saline 500 ml in one hour
After giving 500 ml in one hour, you noticed that there
is clinical improvement. You have sent Hct again. Hct
shows 45% now. How long would you continue the
fluid in this case?
48 hours
Scenario: Dengue fever with
pregnancy
Scenario: Dengue fever with
pregnancy
 A 27-year-old mother in her 2nd pregnancy got admitted at
38 weeks of gestation with a one-day history of high fever,
body ache, eye ache and headache in May. She underwent
lower uterian segment caesarian section (LUCS) due to
obstructed labour in her first pregnancy. On admission, she
was febrile (103 °F). Her pulse rate (PR) and blood pressure
(BP) were 92 beats per minute and 90/60 mm Hg,
respectively. Cardiac and respiratory examination was
unremarkable. She had no complaints of increase frequency
of micturition or burning sensation during micturition.
Abdominal examination revealed a soft abdomen with a single
live fetus and symphysio-fundal height was compatible with
gestational age. Vaginal examination revealed an
unfavorable cervix
 On the 2nd day, she developed two episodes of vomiting and had mild
intermittent abdominal pain. Her PR was 98 beats per minute and
blood pressure was 90/65 mmHg. There was mild right hypochondriac
tenderness. Complete blood count (CBC) showed WBC 6100/mm3,
PLT 62000mm3 and PCV 33%. Ultrasonically, there was no free fluid
in the abdomen or chest. A multidisciplinary team meeting decided to
deliver her baby by urgent LUCS. Decision was executed on that day.

 On the 3rd day, fever was persisting, and she continued to complain of
right hypochondriac pain. She became tachycardic with PR of 105
beats per minute. BP was 90/66 mmHg. CBC revealed WBC of
5300/mm3 with PLT of 55,000/mm3 and PCV of 39%. Ultrasound
(USG) examination showed pericholecystic edema with a thin layer of
free fluid in the hepatorenal pouch

 On day 4 evening, towards the peak of the leaking phase, her PR

started to rise with a narrowing of pulse pressure. There was a sudden
drop in PCV. At the beginning of the second half of the critical phase,
she had developed pedal edema, mild ascites with right-sided mild
pleural effusion without respiratory
What is the most probable diagnosis?
Severe dengue, Group C

 What will be the day 1 management after diagnosis of

dengue fever?
Admission to a hospital for
hospital care

Why the decision of LUCS was taken?

Unfavorable cervix

What measures to keep ready before LUCS?

• 1-unit aphaeretic platelet
• Cross-matched blood and blood products
• Close monitoring as bleeding is
anticipated
Scenario: Dengue with enteric
fever co-infection
 Scenario: Dengue with enteric
fever co-infection
 A 21-year-old boy presented with a 4-day history of high-grade
continued fever, severe headache, myalgia, nausea, and prostration. he
also complained of rash with pruritus for 1 day. On query, he denied
any bleeding from any orifice, abdominal pain, persistent vomiting. On
examination, there was generalized maculo-papular rash with signs of
scoriation mark, blood pressure 110/80 mm Hg, pulse 100/min,
temperature 1020 F. Tourniquet test is positive. Investigations revealed
80 x 109/l platelet counts, 3240/cmm WBC count and positive for
dengue NS1 antigen. There are no features of plasma leakage or
organomegaly. He was managed considering the diagnosis of dengue
fever with warning signs. However, his fever persisted beyond day
seven. On the 8th day, he developed loose motion and pain abdomen
As you are an attending physician, what medical decision
would be best in this situation?

Send blood culture, urine examination

and chest X-ray to exclude any co-
infection
After getting the culture report, what would you do
in this case?

Start antibiotic according to

culture sensitivity considering co-
infection
Ref: Case taken from Advanced Covid 19 clinical management certification course for Bangladesh
Developed by DGHS, HAEFA, Project Hope & Center for Human rights and
humanatarian studies of brown university, usa
http://covidlearning.dghs.gov.bd:8080/
Scenario : Critical Covid 19 case
 A 72-year-old man with one week of fever,
cough, and shortness of breath, you measure
the patient’s oxygen saturation (SpO2) and see
that it is 73%. He reports no close contacts
with COVID-19 to his knowledge. He is alert
and speaking but fatigued and breathless
 Arterial Blood Gas Level

• pH -7.3
• PaO2 -54 mmHg,
• PaCO2-40 mmHg
• HCO3 -22.4 mmol/L.
• SpO2- 87% on 15 L (NRB)
• FiO2- 0.9
• Calculated PaO2/FiO2 is <100
mmhg

 The patient’s RT-PCR results positive for SARS-CoV-2 virus

later that day.
 The patient’s SpO2 is 87% on 15 L/min on non-rebreather
mask (delivering oxygen at 90% Fi02)
 You obtain the chest radiograph and arterial blood gas level.
 What complications developed in this patient ?

Severe acute respiratory distress

syndrome (ARDS) with acute hypoxemic
(Type I) respiratory failure

This patient has severe ARDS.

• Chest X-ray reveals bilateral diffuse opacities without cardiomegaly
• Arterial blood gas level indicates acute hypoxemic type 1 respiratory
failure.
• Ratio of PaO2/FiO2 < 100 mmhg meets the berlin criteria of severe ARDS.
If blood gas level is not available, ratio of SpO2/FiO2 <315 –also diagnostic
of ARDS according to Kigali modification.
Scenario: Covid 19 Complications
 Youare working in the emergency department of a large
referral hospital.

A 54-year-old patient presents with sudden onset moderate

shortness of breath with right sided chest pain for two hours.
The chest pain is described as sharp in nature and increases
during inspiration. There has not been any fever or cough. You
take a history and find out he was hospitalized for COVID-19
and was discharged two weeks ago. Since then, he reports he
had been feeling well except for having palpitations.
Physical Examination
• Temperature 37C (98.6F) • He is speaking in shortened
• Heart rate is 112 beats/min sentences and appears
• BP 110/70 mmHg uncomfortable with deep breathing.
• Respiratory rate 26 breaths/min • Lung auscultation reveals clear lung
fields (vesicular breath sounds),
• SpO2 95% without jugular venous distention
(JVD).
• Cardiovascular examination reveals
tachycardia with regular rhythm.
• Abdomen is soft and non-tender.
• Extremities without oedema and well
perfused.
According to the clinical scenario and ECG findings, what is the most likely
diagnosis here?

Acute pulmonary embolism

Having high index of suspicion is necessary to diagnose

acute pulmonary embolism, especially after COVID-19
infection as thromboembolic complications are well
recognized.
 What is the most common finding of pulmonary
embolism in the ECG of a patient with pulmonary
embolism?

Sinus tachycardia
 This patient’s D-dimer is found to be
3,500ng/ml. He remained tachycardic with
pulse 115 beats/min with BP 110/60 mmHg.
His saturation decreased to 90%. Patient is
immediately placed on supplemental
oxygenation at 6L/min with improvement of
SpO2 to 96%. There are some delays with
obtaining CTPA due to a large numbers of
patient in the hospital. Meanwhile waiting for
CTPA result
 what is the most appropriate next plan of
management?

low-molecular-weight heparin
S/C BID at therapeutic dose
Any patient with raised D-dimer and high suspicion of pulmonary embolism should
immediately get Inj. LMWH (Enoxaparin) at 1mg/kg SC q12hr.
Alternatively UFH or direct oral anticoagulation can be given

Reperfusion is indicated when patient is hemodynamically unstable. This patient is

hemodynamically stable at this point; however they should be monitored closely for
signs of deterioration. If patient rapidly deteriorates, rescue reperfusion is indicated.